Wernicke/Korsakoff (Blair)

• Wernicke = acute neuro change from thiamine deficiency = triad of encephalopathy, oculomotor dysfunction, gait ataxia 
• Korsakoff = chronic sx = antero/retrograde amnesia, confabulations, confusion, apathy 
• Thiamine important in energy production, lipid metabolism
• Most often d/t insufficient intake (alcoholism, starvation/anorexia, etc.), but also from malabsorption, increased metabolic requirements
• Tx: give thiamine (before glucose if they need that too), also give magnesium (as they’re usually hypomagnesemic)

Pheochromocytoma (Mattingly)

• Increased catecholamines d/t rare tumor in adrenal medulla
• Associated with familial syndromes (MEN 2A and 2B)
• Presentation: only 50% are symptomatic with episodic headache, tachycardia, diaphoresis
• Low vs high risk workups, but overall looking for (urine or plasma) metanephrines and catecholamines, if positive then get CT adrenal protocol or PET (usually inpatient side) 
• Treat hypertensive crisis with alpha-blockade (phenoxybenzamine or phentolamine), nitroprusside, or nicardipine; don’t give beta-blocker d/t risk of unopposed alpha activity! Eventually need tumor resection
• Be aware in ED of tumor recurrence even after tumor resection; avoid meds that cause crisis (BB, glucagon, histamine, reglan, corticosteroids)

Pharmacology in Hyperglycemic Crisis (Loudermilk) 

• Be aware of long vs short acting insulin > regular insulin drip is what’s used in DKA 
• Oral/injectable diabetic medications: biguanides (metformin), sulfonylureas (-zides), TZDs (pioglitazone), SGLT2i (jardiance), DPP4 (januvia), GLP-1 agonists (ozempic, trulicity) 
• DKA management: IV fluid therapy with 15-20 mL/kg over 1 hour
• Current protocol does NOT have insulin bolus, so just start the drip 
• Bicarb drip not recommended unless pH < 6.9
• Current order set is only “MED DKA”, but we will soon have ED specific DKA order set includes fluids, insulin gtt, K replacement, labs/VBG/vitals 

Pediatric Seizures (Isacoff) 

• Focal/partial (with or without impairment of consciousness) vs generalized seizures
• ABG/VBG in post-ictal patients not normally helpful – it’s already going to look bad even if not having respiratory failure
• BVM more favorable if still unconscious but starting to wake up, try not to intubate unless absolutely necessary 
• Look for metabolic derangements: sodium, glucose
• Management: ABCs, fyi: succinylcholine contraindicated in suspicion for muscular dystrophy, use roc or vec 
• Anticonvulsant tx for seizure > 5 min: rectal diazepam (home), intranasal versed (0.2mg/kg max 5), or IV ativan (0.1mg/kg up to 4mg)… treat with benzo x3 times, then phenytoin/fosphenytoin or phenobarbital; consider pyridoxine (vit B6) in kids < 1 with refractory seizures 
• Consider CT/MRI if signs of increased ICP, focal/persistent seizure

Diabetic Emergencies (Kuhl)

• 500+ million people affected by diabetes in world
• Common physician pitfalls: delayed ID of DKA, insulin therapy mistakes
• DKA = hyperglycemia + ketones + acidosis (bicarb < 15 or pH < 7.3) 
• HHS = glucose > 600, serum osm > 320, absence of ketoacidosis, presence/absence of coma no longer part of diagnosis 
• Don’t really need ABG/VBG to diagnose DKA (it costs ~ $300), utilize your serum bicarb instead
• End tidal CO2: low for DKA (<21, 100% specific) (d/t increased RR), high then not in DKA (>35, 100% sensitive)
• IV fluid choice: LR better in septic and medicine patients (SMART trial), no significant difference in ICU patients (SALT trial); large boluses of NaCl in DKA has risk of hyperchloremic metabolic acidosis
• Insulin drip 0.1 units/kg/hr going until ketoacidosis is resolved (normalization of pH, bicarb, and closure of anion gap)… NOT guided by blood glucose 
• K management: losing K d/t osmotic diuresis or falsely elevated as it’s extracellular but not in cells; if <3.5 then hold insulin, add in IVF, 3.5-5.5 then start insulin but also give K in IVF, if  >5.5 then just start insulin and no need to supplement
• Pseudohyponatremia – Na decreases by 1.6 for every 100 increase in glucose 
• Most common cause of DKA in US is med nonadherence, infection is 1st outside of US
• Euglycemic DKA possible with SGLT2i
• Consider D10 instead of amp of D50, less caustic and better outcomes